AN UPDATE FOR THE PROVISION OF GENDER AFFIRMING HEALTHCARE ACROSS THE DISTRICT HEALTH BOARDS OF AOTEAROA NEW ZEALAND

By Dr Jeannie Oliphant

A follow-up to the 2019 survey of District Health Board (DHB) clinicians providing gender affirming healthcare was presented at the PATHA symposium in September 2021. Information was sought from clinicians providing gender affirming healthcare in all of the 20 DHBs in New Zealand with the exception of the West Coast DHB for which no appropriate clinician could be identified. While the initial survey in 2019 was unable to obtain information from the Southern DHB there were responses from all 19 DHBs approached in 2021.

In some regions, multiple DHBs share services and resources, such as the Auckland region which is made up of three DHBs: Waitematā, Auckland, and Counties Manukau; the Wellington region which also has three DHBs: Capital and Coast, Hutt, and Wairarapa; and the Canterbury region which has two DHBs: Canterbury and South Canterbury.

Figure 1. Gender affirming healthcare across the 20 DHBs in Aotearoa

Figure 1 compares the availability of gender affirming healthcare between 2019 and 2021. The inner circle in red shows service provision in 2019 compared to the outer ring in green for 2021 with the numbers in the bars showing how many individual DHBs are providing this aspect of healthcare. The 2018 Guidelines for Gender Affirming Healthcare in Aotearoa made a series of recommendations for the provision of gender affirming healthcare in this country including that: DHBs enable flexible and responsive pathways on the basis of informed consent and self-determination and provide clear information about pathways to access gender affirming healthcare services [1].

Clear pathways should be visible to primary and secondary care clinicians and the public. While it is encouraging to see that 11 DHBs now provide referral pathways and information for clinicians to refer for gender affirming healthcare, mostly using the Regional Health Pathways platform, it is disappointing that only six DHBs provide information that is accessible for the general public. This is the three DHBs in Auckland that provide information on Healthpoint, the two DHBs in Canterbury that use Healthinfo Canterbury and Tairāwhiti which includes information on the DHB website. Not knowing where to go was the most commonly reported barrier for accessing hormones in the Counting Ourselves survey [2]. Information on accessing gender affirming healthcare should be displayed clearly along with all the other DHB services.

Another recommendation from the Aotearoa guideline is that health services should enable the involvement of trans and non-binary people, including Māori trans people in decisions that affect them with regard to the development and provision of services.1 The number of DHBs with advisory groups has not changed over time and the groups covering the 10 DHBs are the Auckland Regional Clinical Governance Group – Hauora Tāhine covering three DHBs, the Wellington Sex and Gender Diversity Working Group covering three DHBs and the Christchurch Advisory group covering two DHBs. In addition Taranaki has a group that was described as meeting infrequently and Whanganui are developing a group involving Whanganui PRIDE.

The Aotearoa guidelines recommend that DHBs provide compulsory training for staff on supporting trans and non-binary patients1 and currently only six DHBs provide some form of staff training.

The availability of clinical services has improved in the past two years with the exception of hair removal. While this isn’t a service that is currently provided by DHBs it is an aspect of care that the Counting Ourselves survey highlighted as an important area of unmet need. Responses showed that 40% of participants had self funded to access hair removal and 40% had identified that this was something they wanted but were unable to obtain [2].

Sperm cryopreservation for people whose fertility will be permanently impaired by publicly funded treatment, such as cancer treatments or gender affirming hormones, is publicly funded in New Zealand for those who don’t already have children. This information is available on the Fertility Associates website. While clinics are not present in every region and people may need to travel to access services, for example from Northland to Auckland or Nelson to Christchurch, awareness of services has become more widespread across Aotearoa.  All 19 DHBs provided access to sperm cryopreservation. For Northland and the Auckland DHBs this service is provided by Fertility Plus rather than Fertility Associates.

Speech language therapy services are available in most DHBs and 15 DHBs now provide voice therapy an improvement from 11 in 2019. The Counting Ourselves survey highlighted the importance of voice therapy for different groups of participants with 50% of trans women reporting an unmet need.2 Hopefully, as this is increasingly recognised as being a core component of Gender Affirming Healthcare it will be easier for clinicians to advocate for services in their area.

Most gender affirmation surgery including chest surgery, hysterectomy and orchiectomy is under the elective surgical pathway for each DHB. Genital Gender Affirmation Surgery is not provided by DHBs but is currently being managed nationally through a Ministry of Health waitlist.

Chest reconstruction surgery for transmasculine people is, according to the survey responses, being offered in 10 DHBs across Aotearoa. But in practice, all elective surgical pathways have capacity issues limiting access. One way to manage limited resources is to apply a cap on numbers. Waikato DHB report access to four chest reconstruction surgeries per year with another one or two possible through the general plastics referral pathway. Canterbury and South Canterbury the number is capped at six per year and the demand is such that there is currently a waiting list of people wanting to be referred. For the other smaller DHBs Bay of Plenty, Tairāwhiti, and Southern DHB referrals are considered on a case by case basis. Wellington region surgeries are currently on hold due to staffing shortages and the other DHBs have not had access to chest surgery. The criteria to access chest surgery also varies around the country – Auckland the BMI criteria is less than 30 while Waikato and Bay of Plenty is less than 35. Canterbury region have no hormone requirement while the other DHBs require people to have been on testosterone for a minimum of 12 months. It may be that nationally set criteria to access surgery will be developed with the disestablishment of the DHBs under the New Zealand Health reforms. Certainly at present inequity of service access is a reality for many people living across Aotearoa.

Gender affirming hysterectomy and orchiectomy are currently being offered by 13 DHBs across Aotearoa but often on a case by case basis again for the smaller DHBs and with capped numbers for the Canterbury region.

It is clear from the Counting Ourselves survey that psychological distress is a very common experience for trans and non-binary people in Aotearoa [2] and the New Zealand guidelines recommend that all health services acknowledge the need to support the mental health and wellbeing of trans and non-binary people [1]. All clinicians surveyed recognised the importance of supporting mental health. Different services responded to this need in lots of different ways so it was difficult to summarise in a graphic. Some services involved team members with mental health training and required all people to meet with this team member as part of holistic care and there were lots of examples of DHB funded psychologists providing this service. Sometimes the psychologists were part of the hospital and sometimes they were part of external organisations and services were contracted to the DHB. Other services did not have team members with specific mental health training but would offer referrals to other services as needed and some areas reported that this was an unmet need in their DHB.

In summary, there has been a definite improvement in the availability of gender affirming healthcare services provided by DHBs around Aotearoa. However, this has mostly been due to efforts to improve access to clinical services. It should be acknowledged that provision of clinical services is often championed by individual clinicians in contrast to other aspects of care such as providing clear pathways or advisory groups, which require resourcing by DHB management.

References:

1.      Oliphant J, Veale J, Macdonald J, Carroll R, Johnson R, Harte M, Stephenson C, Bullock J. Guidelines for gender affirming healthcare for gender diverse and transgender children, young people and adults in Aotearoa, New Zealand. Transgender Health Research Lab, University of Waikato, 2018. https://patha.nz/Guidelines

2.      Veale J, Byrne J, Tan K, Guy S, Yee A, Nopera T, Bentham R (2019) Counting Ourselves: The health and wellbeing of trans and non-binary people in Aotearoa New Zealand. Transgender Health Research Lab, University of Waikato: Hamilton NZ. https://countingourselves.nz/index.php/community-report/